真菌性角膜炎药物治疗后转归的共焦显微镜观察

目的探讨共焦显微镜对判断真菌性角膜炎经抗真菌药物治疗后转归的作用,为调整临床用药和选择治疗方案提供客观依据。方法2001年1月至2003年5月我院诊治的328例真菌性角膜炎患者中,选择共焦显微镜检查发现菌丝,溃疡直径≤5mm患者58例(58只眼),常规给予抗真菌药物治疗。分别在治疗前及治疗后7、14、28d和停药后7d对病灶的特定位点进行共焦显微镜检查,观察局部菌丝密度、炎性细胞密度和形态以及角膜基质细胞的变化,以此判断治疗效果,并根据情况调整用药;对共焦显微镜未查见真菌菌丝及炎性细胞的患者,巩固治疗1周后完全停药,并继续随访2个月,以观察有无真菌复发。结果53例患者在药物治疗7d时有明显好转,病灶缩小,共焦显微镜表现为查到菌丝的位点减少,菌丝密度降低,炎性细胞明显减少,形态趋于均匀,同时可见正常形态的角膜基质细胞出现;14d时,37例溃疡愈合,23例共焦显微镜未查见菌丝和炎性细胞;28d时,所有患者的角膜上皮已完全愈合,其中22例共焦显微镜检查仍可见浅基质中存在少量菌丝或未消退的炎性细胞,其余31例患者均未见菌丝和炎性细胞。以上53例位患者在随访期间均未见复发。另5例在用药7d内病情加重,共焦显微镜下见菌丝密度明显增加,炎性细胞增多,角膜基质破坏范围扩大,提示药物治疗效果不佳,故入院行角膜移植术。结论共焦显微镜检查是目前判断真菌性角膜炎药物治疗后病情转归的理想手段,能够为临床调整用药提供客观依据。(中华眼科杂志,2005,41：614-619)

Evaluation of antifungal chemotherapeutic effects on fungal keratitis by confocal microscopy

Objective To evaluate the validity of confocal microscopy in estimating curative effect and in directing the treatment for fungal keratitis in the process of antifungal chemotherapy. Methods Fifty-eight patients, who were confirmed fungal infection by confocal microscopy, were selected from 328 patients with fungal keratitis. All patients received routine topical and/or oral antifungal medication, and were examined by confocal microscopy once a week and one week after discontinuation of the treatment. The density of hyphae in the corneal lesion, the configuration of inflammatory cells and keratocyte were recorded. Antifungal chemotherapy was adjusted according to examination results and medicines were changed accordingly. If no hyphae were detected by confocal microscopy, antifungal medication was maintained for one week and then discontinued. All patients were followed up for two months to ensure no relapse of fungal infection.Results Fifty three patients were cured. The area of corneal lesions began to reduce 7 days after the beginning of antifungal chemotherapy. Confocal microscopy examination revealed that the hypha positive sites and the density of hypha were reduced gradually; inflammatory cells also decreased, the configuration of corneal lesion was transformed from asymmetry to symmetry; and normal keratocytes could be detected gradually. After 14 days of treatment, ulcers healed up in 37 cases and no hyphae and inflammatory cells were found in 23 cases. After 28 days of treatment, all corneal ulcers healed up; hyphae and inflammatory cells were completely disappeared in 31 patients, but a few hyphae still could be found in 22 patients. Antifungal chemotherapy was tapered gradually if no hyphae and inflammatory cells were detected by confocal microscopy. There was no relapse of fungus infection during 2-month follow-up. Infection deteriorated in the other five patients within 7 days, which showed increased density of hypha and inflammatory cells under confocal microscopy examination. All of them were treated with a penetrating keratoplasty to save the eyeball.Conclusions Confocal microscopy is an ideal method for the evaluation of curative effects of fungal keratitis in the process of antifungal chemotherapy. This is also a valuable objective tool in directing antifungal medication.